Patient vs Subject
The |Situation with explicit context (situation)| hierarchy is intended for concepts that explicitly include contextual information. Context can include whom the finding is about, or on whom a procedure is performed. These concepts can be used to represent different meanings, e.g., past history, family history, planned care, excluded diagnosis, etc.
In contrast, a concept in the Clinical Finding or Procedure hierarchy has a default context of the subject of the record. This context can be overridden by the information model.
For example,
- The concept |Asthma (disorder)| could be used in a family history field to represent a family history of asthma.
However, including the term subject or patient within a Clinical finding or Procedure concept prevents that concept’s context from being overridden by the information model.
For example,
- The concept |Patient immunocompromised (finding)| could not be used in a family history field to represent that a family member is immunocompromised.
Therefore, the use of patient and subject should be used only when necessary.
Descriptions should use the word subject, not patient, if required, as subject is broader than patient.
For example,
Subject refers to the subject of record, who may, in some circumstances, not be the patient.
Best practice is to create a contextless concept.
Example - finding,
- Patient unable to chew with denture (finding) - incorrect
- Unable to chew with denture (finding) - correct
Example - procedure,
- Positioning subject in supine position (procedure) -incorrect
- Positioning in supine position (procedure) - correct
Caregiver vs Carer
Descriptions with caregiver should be as follows:
- An FSN should use caregiver as (one word).
- There should be a synonym using carer.
For example,
- 425578005 | Caregiver able to cope (finding)|
- Synonym: Carer able to cope
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